Student Registration

State*	New South Wales Victoria Queensland South Australia Northern Territory Western Australia Tasmania Australian Capital Territory
School/University/TAFE*
Year	High School - Year 9 High School - Year 10 High School - Year 11 High School - Year 12 Uni - 1st Year Uni - 2nd Year Uni - 3rd Year Uni - 4th Year Uni - Postgrad
If you attend a University or TAFE please specify your area of study or name of course
Student Info
Title	Mr Miss Mrs Ms Dr Prof
First Name*
Surname*
DOB*	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909
Gender*	Male Female
Phone*
Email
Mobile
Address
Street*
Street 2
Suburb*
Postcode*
Preferred Day 1	Select a Day Monday Tuesday Wednesday Thursday
Preferred Suburb 1
Preferred Day 2	Select a Day Monday Tuesday Wednesday Thursday
Preferred Suburb 2
Young Achievement Australia Statistical Information
This information will remain confidential and is to be used by Young Achievement Australia for statistical purposes only.
Are you of Aboriginal or Torres Strait Islander descent?
	No Yes
Are you an Australian citizen, Permanent Resident of Australia or hold an Australian Humanitarian Visa?
	Yes No
Privacy
All applications and personal information will be treated in strict confidence and Young Achievement Australia is bound by legislation to ensure that files containing personal information are accessed only by those people who have the need to know and stored in a secure place to ensure that a high level of security is maintained at all times.
Declaration
I confirm that all information provided in this application is correct and accurate. I acknowledge that completing this application may not necessarily result in me being placed in a program but that Young Achievement Australia will endeavour to place me and accommodate my preferences.
I agree to the above declaration
What is the text in the box below?